Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

Macroeconomic conditions and opioid abuse

We examine how deaths and emergency department (ED) visits related to use of opioid analgesics (opioids) and other drugs vary with macroeconomic conditions. As the county unemployment rate increases by one percentage point, the opioid death rate per 100,000 rises by 0.19 (3.6%) and the opioid overdose ED visit rate per 100,000 increases by 0.95 (7.0%). Macroeconomic shocks also increase the overall drug death rate, but this increase is driven by rising opioid deaths. Our findings hold when performing a state-level analysis, rather than county-level; are primarily driven by adverse events among whites; and are stable across time periods.

The opioid crisis: past, present and future policy climate in Ontario, Canada

BACKGROUND

Addressing opioid use disorder has become a priority in Ontario, Canada, because of its high economic, social and health burden. There continues to be stigma and criticism relating to opioid use disorder and treatment options. The result has been unsystematic, partial, reactive policies and programs developed based on divergent points of view. The aim of this manuscript is to describe how past and present understandings, narratives, ideologies and discourse of opioid use, have impacted policies over the course of the growing opioid crisis.

COMMENTARY

Assessing the impact of policy is complex. It involves consideration of conceptual issues of what impacts policy change. In this manuscript we argue that the development of polices and initiatives regarding opioids, opioid use disorder and opioid agonist treatment in the last decade, have been more strongly associated with the evolution of ideas, narratives and discourses rather than research relating to opioids. We formulate our argument using a framework by Sumner, Crichton, Theobald, Zulu, and Parkhurs. We use examples from the Canadian context to outline our argument such as: the anti- drug legislation from the Canadian Federal Conservative government in 2007; the removal of OxyContin™ from the drug formulary in 2012; the rapid expansion of opioid agonist treatment beginning in the early 2000s, the unilateral decision made regarding fee cuts for physicians providing opioid agonist treatment in 2015; and the most recent implementation of a narcotics monitoring system, which are all closely linked with the shifts in public opinion and discourse at the time of which these policies and programs are implemented.

CONCLUSION

We conclude with recommendations to consider a multifactorial response using evidence and stakeholder engagement to address the opioid crisis, rather than a reactive policy approach. We suggest that researchers have an important role in shaping future policy by reframing ideas through knowledge translation, formation of values, creation of new knowledge and adding to the quality of public discourse and debate.

Cost-effectiveness of emergency department-initiated treatment for opioid dependence

BACKGROUND AND AIMS

In a recent randomized trial, patients with opioid dependence receiving brief intervention, emergency department (ED)-initiated buprenorphine and ongoing follow-up in primary care with buprenorphine (buprenorphine) were twice as likely to be engaged in addiction treatment compared with referral to community-based treatment (referral) or brief intervention and referral (brief intervention). Our aim was to evaluate the relative cost-effectiveness of these three methods of intervening on opioid dependence in the ED.

DESIGN

Measured health-care use was converted to dollar values. We considered a health-care system perspective and constructed cost-effectiveness acceptability curves that indicate the probability each treatment is cost-effective under different thresholds of willingness-to-pay for outcomes studied.

SETTING

An urban ED in the United States.

PARTICIPANTS

Opioid-dependent patients aged 18 years or older.

MEASUREMENTS

Self-reported 30-day assessment data were used to construct cost-effectiveness acceptability curves for patient engagement in formal addiction treatment at 30 days and the number of days illicit opioid-free in the past week.

FINDINGS

Considering only health-care system costs, cost-effectiveness acceptability curves indicate that at all positive willingness-to-pay values, ED-initiated buprenorphine treatment was more cost-effective than brief intervention or referral. For example, at a willingness-to-pay threshold of $1000 for 30-day treatment engagement, we are 79% certain ED-initiated buprenorphine is most cost-effective compared with other studied treatments. Similar results were found for days illicit opioid-free in the past week. Results were robust to secondary analyses that included patients with missing cost data, included crime and patient time costs in the numerator, and to changes in unit price estimates.

CONCLUSION

In the United States, emergency department-initiated buprenorphine intervention for patients with opioid dependence provides high value compared with referral to community-based treatment or combined brief intervention and referral.

Prescription Opioid Misuse Among Rural Community Pharmacy Patients: Pilot Study for Screening and Implications for Future Practice and Research

BACKGROUND

Opioid misuse imposes a disproportionately heavy burden on individuals living in rural areas. Community pharmacy has the potential to expand and coordinate with health professionals to identify and intervene with those who misuse opioids.

OBJECTIVE

Rural and urban community pharmacy patients were recruited in this pilot project to describe and compare patterns of opioid misuse.

METHODS

We administered a health screening survey in 4 community pharmacies among patients filling opioid medications. Univariate statistics were used to assess differences in health characteristics and opioid medication misuse behaviors between rural and urban respondents. Multivariable statistics were used to identify risk factors associated with rural and urban opioid misuse.

RESULTS

A total of 333 participants completed the survey. Participants in rural settings had poorer overall health, higher pain levels, lower education, and a higher rate of unemployment compared to patients in urban pharmacies. Rural respondents with illicit drug use (adjustable odds ratio [aOR]: 14.34, 95% confidence interval [CI] = 2.16-95.38), posttraumatic stress disorder (aOR: 5.44, 95% CI = 1.52-19.50), and ≤high school education (aOR: 6.68, 95% CI = 1.06-42.21) had increased risk for opioid misuse.

CONCLUSIONS

Community pharmacy represents a promising resource for potential identification of opioid misuse, particularly in rural communities. Continued research must extend these findings and work to establish collaborative services in rural settings.

Hospitalizations, costs and outcomes associated with heroin and prescription opioid overdoses in the United States 2001-12

BACKGROUND AND AIMS

The full burden of the opioid epidemic on US hospitals has not been described. We aimed to estimate how heroin (HOD) and prescription opioid (POD) overdose-associated admissions, costs, outcomes and patient characteristics have changed from 2001 to 2012.

DESIGN

Retrospective cohort study of hospital admissions from the National Inpatient Sample (NIS).

SETTING

United States of America.

PARTICIPANTS

Hospital admissions in patients aged 18 years or older admitted with a diagnosis of HOD or POD. The NIS sample included 94 492 438 admissions from 2001 to 2012. The final unweighted study sample included 138 610 admissions (POD: 122 147 and HOD: 16 463).

MEASUREMENTS

Primary outcomes were rates of admissions per 100 000 people using US Census Bureau annual estimates. Other outcomes included in-patient mortality, hospital length-of-stay, cumulative and mean hospital costs and patient demographics. All analyses were weighted to provide national estimates.

FINDINGS

Between 2001 and 2012, an estimated 663 715 POD and HOD admissions occurred nation-wide. HOD admissions increased 0.11 per 100 000 people per year [95% confidence interval (CI) = 0.04, 0.17], while POD admissions increased 1.25 per 100 000 people per year (95% CI = 1.15, 1.34). Total in-patient costs increased by $4.1 million dollars per year (95% CI = 2.7, 5.5) for HOD admissions and by $46.0 million dollars per year (95% CI = 43.1, 48.9) for POD admissions, with an associated increase in hospitalization costs to more than $700 million annually. The adjusted odds of death in the POD group declined modestly per year [odds ratio (OR) = 0.98, 95% CI = 0.97, 0.99], with no difference in HOD mortality or length-of-stay. Patients with POD were older, more likely to be female and more likely to be white compared with HOD patients.

CONCLUSIONS

Rates and costs of heroin and prescription opioid overdose related admissions in the United States increased substantially from 2001 to 2012. The rapid and ongoing rise in both numbers of hospitalizations and their costs suggests that the burden of POD may threaten the infrastructure and finances of US hospitals.

Advances in the delivery of buprenorphine for opioid dependence

Opioid use disorders (OUDs) have long been a global problem, but the prevalence rates have increased over 20 years to epidemic proportions in the US, with concomitant increases in morbidity and all-cause mortality, but especially opioid overdose. These increases are in part attributable to a several-fold expansion in the prescription of opioid pain medications over the same time period. Opioid detoxification and psychosocial treatments alone have each not yielded sufficient efficacy for OUD, but μ-opioid receptor agonist, partial agonist, and antagonist medications have demonstrated the greatest overall benefit in OUD treatment. Buprenorphine, a μ-opioid receptor partial agonist, has been used successfully on an international basis for several decades in sublingual tablet and film preparations for the treatment of OUD, but the nature of formulation, which is typically self-administered, renders it susceptible to nonadherence, diversion, and accidental exposure. This article reviews the clinical trial data for novel buprenorphine delivery systems in the form of subcutaneous depot injections, transdermal patches, and subdermal implants for the treatment of OUD and discusses both the clinical efficacy of longer-acting formulations through increasing consistent medication exposure and their potential utility in reducing diversion. These new delivery systems also offer new dosing opportunities for buprenorphine and strategies for dosing intervals in the treatment of OUD.

Cost-effectiveness of extended release naltrexone to prevent relapse among criminal justice-involved individuals with a history of opioid use disorder

BACKGROUND AND AIMS

Criminal justice-involved individuals are highly susceptible to opioid relapse and overdose-related deaths. In a recent randomized trial, we demonstrated the effectiveness of extended-release naltrexone (XR-NTX; Vivitrol® ) in preventing opioid relapse among criminal justice-involved US adults with a history of opioid use disorder. The cost of XR-NTX may be a significant barrier to adoption. Thus, it is important to account for improved quality of life and downstream cost-offsets. Our aims were to (1) estimate the incremental cost per quality-adjusted life-year (QALY) gained for XR-NTX versus treatment as usual (TAU) and evaluate it relative to generally accepted value thresholds; and (2) estimate the incremental cost per additional year of opioid abstinence.

DESIGN

Economic evaluation of the aforementioned trial from the taxpayer perspective. Participants were randomized to 25 weeks of XR-NTX injections or TAU; follow-up occurred at 52 and 78 weeks.

SETTING

Five study sites in the US Northeast corridor.

PARTICIPANTS

A total of 308 participants were randomized to XR-NTX (n = 153) or TAU (n = 155).

MEASUREMENTS

Incremental costs relative to incremental economic and clinical effectiveness measures, QALYs and abstinent years, respectively.

FINDINGS

The 25-week cost per QALY and abstinent-year figures were $162 150 and $46 329, respectively. The 78-week figures were $76 400/QALY and $16 371/abstinent year. At 25 weeks, we can be 10% certain that XR-NTX is cost-effective at a value threshold of $100 000/QALY and 62% certain at $200 000/QALY. At 78 weeks, the cost-effectiveness probabilities are 59% at $100 000/QALY and 76% at $200 000/QALY. We can be 95% confident that the intervention would be considered 'good value' at $90 000/abstinent year at 25 weeks and $500/abstinent year at 78 weeks.

CONCLUSIONS

While extended-release naltrexone appears to be effective in increasing both quality-adjusted life-years (QALYs) and abstinence, it does not appear to be cost-effective using generally accepted value thresholds for QALYs, due to the high price of the injection.

Opioid Use Disorder and Pregnancy

Over-prescription of opioid pain medications and increases in heroin use have contributed to the sharp rise in opioid-related hospitalizations and overdose deaths among young adults in the United States, including pregnant women. This has imposed substantial direct and indirect costs to our nation's health care system. Effective treatment with methadone and buprenorphine is available, but significant barriers to care may restrict access for many. Improved screening tools and expanded access to treatments for substance use disorders are keys to addressing the epidemic of opioid use disorder.

The costs of crime during and after publicly funded treatment for opioid use disorders: a population-level study for the state of California

BACKGROUND AND AIMS

Treatment for opioid use disorders (OUD) reduces the risk of mortality and infectious disease transmission; however, opportunities to quantify the potential economic benefits of associated decreases in drug-related crime are scarce. This paper aimed to estimate the costs of crime during and after periods of engagement in publicly funded treatment for OUD to compare total costs of crime during a hypothetical 6-month period following initiation of opioid agonist treatment (OAT) versus detoxification.

DESIGN

Retrospective, administrative data-based cohort study with comprehensive information on drug treatment and criminal justice systems interactions.

SETTING

Publicly funded drug treatment facilities in California, USA (2006-10).

PARTICIPANTS

A total of 31 659 individuals admitted for the first time to treatment for OUD, and who were linked with criminal justice and mortality data, were followed during a median 2.3 years. Median age at first treatment admission was 32, 35.8% were women and 37.1% primarily used prescription opioids.

MEASUREMENTS

Daily costs of crime (US$2014) were calculated from a societal perspective and were composed of the costs of policing, court, corrections and criminal victimization. We estimated the average marginal effect of treatment engagement in OAT or detoxification adjusting for potential fixed and time-varying confounders, including drug use and criminal justice system involvement prior to treatment initiation.

FINDINGS

Daily costs of crime during treatment compared with after treatment were $126 lower for OAT [95% confidence interval (CI) = $116, $136] and $144 lower for detoxification (95% CI = $135, $154). Summing the costs of crime during and after treatment over a hypothetical 6-month period using the observed median durations of OAT (161 days) and detoxification (19 days), we estimated that enrolling an individual in OAT as opposed to detoxification would save $17 550 ($16 840, $18 383).

CONCLUSIONS

In publicly funded drug treatment facilities in California, USA, engagement in treatment for opioid use disorders is associated with lower costs of crime in the 6 months following initiation of treatment, and the economic benefits were far greater for individuals receiving time-unlimited treatment.

Drivers of excess costs of opioid abuse among a commercially insured population

OBJECTIVES

To replicate and extend a recently published analysis of the drivers of excess costs of opioid abuse.

STUDY DESIGN

Retrospective data analysis using de-identified claims data from the Truven MarketScan Commercial Claims and Encounter database.

METHODS

Medical and prescription drug claims from beneficiaries covered by large self-insured US companies were used to select patients with incident diagnoses of opioid abuse between 2012 and 2015. Two cohorts, abusers and nonabusers, were matched using propensity score methods. Excess healthcare costs were estimated over a 6-month baseline period and 12-month follow-up period. Cost drivers were assessed by diagnosis (3-digit International Classification of Diseases, Ninth Revision, Clinical Modification groupings) and place of service.

RESULTS

The analysis included 73,714 matched pairs of abusers and nonabusers. Relative to nonabusers, abusers had considerably higher annual healthcare costs of $10,989 per patient, or $1.98 per member per month. Excess costs were similar, yet lower, than the previous analysis using another commercial claims database. In both analyses, a ramp-up in excess costs was observed prior to the incident abuse diagnosis, followed by a decline post diagnosis, although not to baseline levels. Key drivers of excess costs in the 2 studies included opioid use disorders, nonopioid substance misuse, and painful and mental health conditions. From 2010 to 2014, the prevalence of diagnosed opioid abuse doubled, with incidence rates exhibiting an increasing, though flatter, trend than earlier in the period.

CONCLUSIONS

Opioid abuse imposes a considerable economic burden on payers. Many abusers have complex healthcare needs and may require care beyond that which is required to treat opioid abuse. These results are robust and consistent across different data sources.

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation

BACKGROUND

Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system.

OBJECTIVE

The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective.

METHODS

We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED.

RESULTS

By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07).

CONCLUSION

The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

A Proposed Solution to the High Cost of Opioid Abuse

Through collaboration, safety professionals and physical therapists can achieve optimal results with both prevention and post-injury management.

Economic conditions, illicit drug use, and substance use disorders in the United States

We provide the first analysis of the relationship between economic conditions and the use of illicit drugs other than marijuana. Drawing on US data from 2002 to 2015, we find mixed evidence on the cyclicality of illicit drug use. However, we find robust evidence that economic downturns lead to increases in the intensity of prescription pain reliever use as well as increases in clinically relevant substance use disorders involving opioids. These effects are concentrated among working-age white males with low educational attainment. We conclude that policymakers should consider devoting more, not fewer, resources to treating substance use disorders during economic downturns.

A systematic review of health economic models of opioid agonist therapies in maintenance treatment of non-prescription opioid dependence

BACKGROUND

Opioid dependence is a chronic condition with substantial health, economic and social costs. The study objective was to conduct a systematic review of published health-economic models of opioid agonist therapy for non-prescription opioid dependence, to review the different modelling approaches identified, and to inform future modelling studies.

METHODS

Literature searches were conducted in March 2015 in eight electronic databases, supplemented by hand-searching reference lists and searches on six National Health Technology Assessment Agency websites. Studies were included if they: investigated populations that were dependent on non-prescription opioids and were receiving opioid agonist or maintenance therapy; compared any pharmacological maintenance intervention with any other maintenance regimen (including placebo or no treatment); and were health-economic models of any type.

RESULTS

A total of 18 unique models were included. These used a range of modelling approaches, including Markov models (n = 4), decision tree with Monte Carlo simulations (n = 3), decision analysis (n = 3), dynamic transmission models (n = 3), decision tree (n = 1), cohort simulation (n = 1), Bayesian (n = 1), and Monte Carlo simulations (n = 2). Time horizons ranged from 6 months to lifetime. The most common evaluation was cost-utility analysis reporting cost per quality-adjusted life-year (n = 11), followed by cost-effectiveness analysis (n = 4), budget-impact analysis/cost comparison (n = 2) and cost-benefit analysis (n = 1). Most studies took the healthcare provider's perspective. Only a few models included some wider societal costs, such as productivity loss or costs of drug-related crime, disorder and antisocial behaviour. Costs to individuals and impacts on family and social networks were not included in any model.

CONCLUSION

A relatively small number of studies of varying quality were found. Strengths and weaknesses relating to model structure, inputs and approach were identified across all the studies. There was no indication of a single standard emerging as a preferred approach. Most studies omitted societal costs, an important issue since the implications of drug abuse extend widely beyond healthcare services. Nevertheless, elements from previous models could together form a framework for future economic evaluations in opioid agonist therapy including all relevant costs and outcomes. This could more adequately support decision-making and policy development for treatment of non-prescription opioid dependence.

Characteristics and treatment patterns of US commercially insured and Medicaid patients with opioid dependence or abuse

OBJECTIVE

To identify the demographic and clinical characteristics of commercially insured and Medicaid patients with a diagnosis of opioid dependence or abuse and to describe the pharmacological and nonpharmacological treatments received by these patients.

DESIGN

This was a retrospective observational study using de-identified administrative claims data.

SETTING

The analysis included commercially insured and Medicaid patient data extracted from the Truven Health MarketScan® Commercial and Medicaid Databases.

PATIENTS

Patients with a diagnosis of opioid dependence or abuse from 2008 to 2014 (earliest diagnosis = index date) and a minimum of 6 months of pre-index and postindex continuous enrollment in the database.

MAIN OUTCOME MEASURE(S)

Baseline demographic and clinical characteristics, medication-assisted treatment (MAT), and treatment other than MAT received following diagnosis, and the clinical practice setting in which patients received any opioid dependence-related care were reported.

RESULTS

Data from commercially insured (N = 103,768) and Medicaid (N = 50,552) patients were analyzed. Common comorbid conditions included chronic pain (48.6 percent Commercial, 56.8 percent Medicaid), depressive disorder (24.0 percent Commercial, 32.8 percent Medicaid), and other substance abuse disorders (13.3 percent Commercial, 23.7 percent Medicaid). Nearly one third of both Commercial (31.6 percent) and Medicaid (33.6 percent) patients did not have any claims for psychosocial therapy or MAT during the follow-up period. Only 24.3 percent of Commercial patients and 20.4 percent of Medicaid patients had evidence of claims for both MAT and psychosocial treatment anytime following diagnosis.

CONCLUSIONS

The results suggest that there are opportunities to improve care through comprehensive and coordinated treatment for opioid dependence/abuse. Policies aimed at improving treatment access may be warranted.

The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013

IMPORTANCE

It is important to understand the magnitude and distribution of the economic burden of prescription opioid overdose, abuse, and dependence to inform clinical practice, research, and other decision makers. Decision makers choosing approaches to address this epidemic need cost information to evaluate the cost effectiveness of their choices.

OBJECTIVE

To estimate the economic burden of prescription opioid overdose, abuse, and dependence from a societal perspective.

DESIGN, SETTING, AND PARTICIPANTS

Incidence of fatal prescription opioid overdose from the National Vital Statistics System, prevalence of abuse and dependence from the National Survey of Drug Use and Health. Fatal data are for the US population, nonfatal data are a nationally representative sample of the US civilian noninstitutionalized population ages 12 and older. Cost data are from various sources including health care claims data from the Truven Health MarketScan Research Databases, and cost of fatal cases from the WISQARS (Web-based Injury Statistics Query and Reporting System) cost module. Criminal justice costs were derived from the Justice Expenditure and Employment Extracts published by the Department of Justice. Estimates of lost productivity were based on a previously published study.

EXPOSURE

Calendar year 2013.

MAIN OUTCOMES AND MEASURES

Monetized burden of fatal overdose and abuse and dependence of prescription opioids.

RESULTS

The total economic burden is estimated to be $78.5 billion. Over one third of this amount is due to increased health care and substance abuse treatment costs ($28.9 billion). Approximately one quarter of the cost is borne by the public sector in health care, substance abuse treatment, and criminal justice costs.

CONCLUSIONS AND RELEVANCE

These estimates can assist decision makers in understanding the magnitude of adverse health outcomes associated with prescription opioid use such as overdose, abuse, and dependence.

Economic Burden of Prescription Opioid Misuse and Abuse: A Systematic Review

A 2009 systematic review found that the total cost of prescription opioid abuse in 2001 in the United States was approximately $8.6 billion and medical expenses were estimated to be $15,884 for opioid abusers and $1,830 for nonabusers. A search was conducted for English publications on the cost of prescription opioid abuse and misuse from 2009 to 2014. The initial literature search identified 5,412 citations. Title and abstract review selected 59 for further review. The final review process resulted in 16 publications for inclusion that examined cost from the payer perspective. Mean costs to the payer for abusers were $23,000-$25,000 per year and excess costs approximately $15,000 per patient. Three papers were identified that presented societal costs, including direct and indirect costs such as criminal justice costs and costs associated with lost productivity. The strongest evidence suggests that societal cost is in excess of $50 billion per year in the United States. Prescription opioid abuse and misuse is a common and important problem throughout the world that has significant associated societal costs and excess medical costs.

Economic Evaluations of Opioid Use Disorder Interventions

BACKGROUND

The economic costs associated with opioid misuse are immense. Effective interventions for opioid use disorders are available; however, given the scarce resources faced by substance use treatment providers and payers of all kinds, evidence of effectiveness is not always sufficient to encourage adoption of a given therapy-nor should it be. Economic evaluations can provide evidence that will help stakeholders efficiently allocate their resources.

OBJECTIVE

The purpose of this study was to review the literature on economic evaluations of opioid use disorder interventions.

METHODS

We performed a systematic review of the major electronic databases from inception until August 2015. A sensitive approach was used to ensure a comprehensive list of relevant articles. Given the quality of the existing reviews, we narrowed our search to studies published since 2007. The Drummond checklist was used to evaluate and categorize economic evaluation studies according to their quality.

RESULTS

A total of 98 articles were identified as potentially relevant to the current study. Of these 98 articles, half (n = 49) were included in this study. Six of the included articles were reviews. The remaining 43 articles reported economic evaluation studies of interventions for opioid use disorders. In general, the evidence on methadone maintenance therapy (MMT) supports previous findings that MMT is an economically advantageous opioid use disorder therapy. The economic literature comparing MMT with other opioid use disorder pharmacotherapies is limited, as is the literature on other forms of therapy.

CONCLUSION

With the possible exception of MMT, additional high-quality economic evaluations are needed in order to assess the relative value of existing opioid use disorder interventions.

Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison

AIMS

To assess the effectiveness for Scotland's National Naloxone Programme (NNP) by comparison between 2006-10 (before) and 2011-13 (after NNP started in January 2011) and to assess cost-effectiveness.

DESIGN

This was a pre-post evaluation of a national policy. Cost-effectiveness was assessed by prescription costs against life-years gained per opioid-related death (ORD) averted.

SETTING

Scotland, in community settings and all prisons.

INTERVENTION

Brief training and standardized naloxone supply became available to individuals at risk of opioid overdose.

MEASUREMENTS

ORDs as identified by National Records of Scotland. Look-back determined the proportion of ORDs who, in the 4 weeks before ORD, had been (i) released from prison (primary outcome) and (ii) released from prison or discharged from hospital (secondary). We report 95% confidence intervals for effectiveness in reducing the primary (and secondary) outcome in 2011-13 versus 2006-10. Prescription costs were assessed against 1 or 10 life-years gained per averted ORD.

FINDINGS

In 2006-10, 9.8% of ORDs (193 of 1970) were in people released from prison within 4 weeks of death, whereas only 6.3% of ORDs in 2011-13 followed prison release (76 of 1212, P < 0.001; this represented a difference of 3.5% [95% confidence interval (CI) = 1.6-5.4%)]. This reduction in the proportion of prison release ORDs translates into 42 fewer prison release ORDs (95% CI = 19-65) during 2011-13, when 12,000 naloxone kits were issued at current prescription cost of £225,000. Scotland's secondary outcome reduced from 19.0 to 14.9%, a difference of 4.1% (95% CI = 1.4-6.7%).

CONCLUSIONS

Scotland's National Naloxone Programme, which started in 2011, was associated with a 36% reduction in the proportion of opioid-related deaths that occurred in the 4 weeks following release from prison.

A randomized controlled trial of the effects of working memory training in methadone maintenance patients

OBJECTIVE

Working memory impairment in individuals with chronic opioid dependence can play a major role in cognitive and treatment outcomes. Cognitive training targeting working memory shows promise for improved function in substance use disorders. To date, cognitive training has not been incorporated as an adjunctive treatment for opioid dependence.

METHODS

Methadone maintenance patients were randomly assigned to experimental (n=28) or active control (n=28) 25-session computerized training and run in parallel. Cognitive and drug use outcomes were assessed before and after training.

RESULTS

Participants in the experimental condition showed performance improvements on two of four working memory measures, and both groups improved on a third measure of working memory performance. Less frequent drug use was found in the experimental group than in the control group post-training. In contrast to previous findings with stimulant users, no significant effect of working memory training on delay discounting was found using either hypothetical or real rewards. There were no group differences on working memory outcome measures that were dissimilar from the training tasks, suggesting that another mechanism (e.g., increased distress tolerance) may have driven drug use results.

CONCLUSIONS

Working memory training improves performance on some measures of working memory in methadone maintenance patients, and may impact drug use outcomes. Working memory training shows promise in patients with substance use disorders; however, further research is needed to understand the mechanisms through which performance is improved and drug use outcomes are impacted.